MEDICARE: JOHN P PETERSEN MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	920004346	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215151113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN P PETERSEN MD PA

Provider Business Mailing Address
First Line	:	PO BOX 100013
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-0013
Country	:	US
Telephone Number	:	770-693-5818
Fax Number	:	770-693-5821

Provider Business Practice Location Address
First Line	:	3555 10TH CT
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-5013
Country	:	US
Telephone Number	:	772-794-3333
Fax Number	:	772-569-6949

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. JOHN PETER PETERSEN
Credential	:	MD
Telephone Number	:	772-794-3333

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	03/25/2020

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